HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2018 List of Covered Drugs (Formulary)

Transcription

1 HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in HealthPartners MSHO. HealthPartners is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in HealthPartners depends on contract renewal. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copays may change on January 1 of each year. You can always check HealthPartners MSHO s up-to-date List of Covered Drugs online at healthpartners.com/medicarerx. Limitations, copays, and restrictions may apply. For more information, call HealthPartners MSHO Member Services at the number listed at the bottom of this page or read the HealthPartners MSHO Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. You can get this document for free in other formats, such as large print, braille or audio. Call Member Services at the number listed at the bottom of this page. You can make a standing request to get materials, now and in the future, in a language other than English or in an alternate format. Call Member Services at the number listed at the bottom of this page Updated 07/18 If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017

2 American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-2

3 Frequently Asked Questions (FAQ) Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List that starts on page 3 are the drugs covered by HealthPartners MSHO. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. HealthPartners MSHO will cover all medically necessary drugs on the Drug List if: Your doctor or other prescriber says you need them to get better or stay healthy, and You fill the prescription at a HealthPartners MSHO network pharmacy. HealthPartners MSHO may have additional steps to access certain drugs (see question 5 below). You can also see an up-to-date list of drugs we cover on our website at healthpartners.com/medicarerx or call Member Services at the number listed at the bottom of this page. 2. Does the Drug List ever change? Yes. HealthPartners MSHO may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: A cheaper drug comes along that works as well as a drug on the Drug List now, or We learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior authorization for a drug. (Prior authorization is permission from HealthPartners MSHO before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see questions 5, 6 and 7.) If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-3

4 We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4 and 7 have more information on what happens when the Drug List changes. You can always check HealthPartners MSHO s current Drug List online at healthpartners.com/medicarerx. You can also call Member Services at the number listed at the bottom of this page to check the current Drug List. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed from the Drug List because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will get this notification in your monthly Part D Explanation of Benefits. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please follow the instructions in the letter and talk to your doctor. 5. Are there any restrictions or limits on drug coverage? Or are there any actions required to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you, your doctor, or other prescriber must do something before you can get the drug. For example: Prior authorization: For some drugs, you, your doctor, or other prescriber must get authorization from HealthPartners MSHO before you fill your prescription. If you don t get authorization, HealthPartners MSHO may not cover the drug. Quantity limits: Sometimes HealthPartners MSHO limits the amount of a drug you can get. Step therapy: Sometimes HealthPartners MSHO requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at healthpartners.com/medicarerx. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-4

5 You can ask for an exception to these limits. Please see questions 9-13 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new HealthPartners MSHO member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see questions 9-13 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are any actions required to get the drug? The Drug List on page 3 has a column labeled. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization, quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior authorization, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other provider about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by drug type. To search alphabetically, go to the Index. You can find it in the back of this book. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the Index. To search by drug type, find the section labeled List of drugs by drug type on page 1. The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-5

6 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at the number listed at the bottom of this page and ask about it. If you learn that HealthPartners MSHO will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions for more information about exceptions. 10. What if you are a new HealthPartners MSHO member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of HealthPartners MSHO. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: You are taking a drug that is not on our Drug List, or Health plan rules do not let you get the amount ordered by your prescriber, or The drug requires prior authorization by HealthPartners MSHO, or You are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. For existing members who change care level, such as entering a long-term care facility or being discharged from a hospital, we ll grant early refills when appropriate. Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can t be used to buy a non-part D drug or a drug out of network, unless you qualify for out of network access. See your Member Handbook for information about non-part D drugs. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-6

7 11. Can you ask for an exception to cover your drug? Yes. You can ask HealthPartners MSHO to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, HealthPartners MSHO may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior authorization requirements. 12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. 14. What are generic drugs? drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. drugs are approved by the Food and Drug Administration (FDA). HealthPartners MSHO covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. HealthPartners MSHO offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-7

8 16. Does HealthPartners MSHO cover non-drug OTC products? HealthPartners MSHO covers some non-drug OTC products through Medical Assistance (Medicaid). These non-drug OTC products are listed in this Drug List. 17. Can I get my drugs through Mail Order and Long-Term Supply? Mail Order Program. We offer a mail order program that allows you to get up to a 90-day supply of your prescription drugs sent directly to your home. A 90-day supply has the same copay as a one-month supply. Long-Term Supply. We offer a way to get a long-term supply of maintenance drugs on our plan s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) For more information about getting drugs through mail order or long-term supply, please call Member Services at the number listed at the bottom of this page. 18. What is your copay? You can read the HealthPartners MSHO Drug List to learn about the copay for each drug. A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $1.20 for a prescription drug. HealthPartners MSHO members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. The Drug List includes copays listed by tiers. Tier 1 drugs have the lowest copay. The copay is from $0 to $3.35, depending on your income and level of Medical Assistance (Medicaid) eligibility. Tier 1 drugs have a higher copay. The copay is from $0 to $8.35, depending on your income and level of Medical Assistance (Medicaid) eligibility. OTCs have a $0 copay. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-8

9 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by HealthPartners MSHO. If you have trouble finding your drug in the list, turn to the Index that begins on page 149. The first column of the chart lists the name of the drug. drugs are listed in lowercase italics (e.g., atorvastatin), brand name drugs are capitalized (e.g., HUMALOG), and OTC drugs and products are listed in lowercase (e.g., guaifenesin). The information in the column tells you if HealthPartners MSHO has any rules for covering your drug. The key below describes the abbreviations used in the column. ABBREVIATION QL BvD ST LA DESCRIPTION Prior Authorization Required Quantity Limit This drug could be covered as a Part B or a Part D Benefit. Step Therapy Required Limited Access Drug Some drugs may be available only at certain pharmacies. For more information consult your pharmacy directory or call Member Services. Non-Mail Order Drug Drugs not eligible for a 90-day mail order supply through your mail order benefit are noted with under Requirements/Limits. If you have questions, please call HealthPartners MSHO Member Services at or , TTY/TDD 711, Oct. 1 through Feb. 14, 8 a.m. to 8 p.m., seven days a week. Feb. 15 through Sept. 30, 8 a.m. to 8 p.m. Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_103170_01 Approved 9/6/2017 I-9

10 List of Drugs by Drug Type Table of Contents Analgesics... 3 Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents...11 Antibacterials Anticancer Agents...20 Anticholinergic Agents Anticonvulsants...31 Antidementia Agents...35 Antidepressants Antidiabetic Agents...38 Antifungals...43 Antigout Agents Antihistamines...46 Anti-Infectives (Skin And Mucous Membrane)...47 Antimigraine Agents Antimycobacterials...49 Antinausea Agents...49 Antiparasite Agents...51 Antiparkinsonian Agents...52 Antipsychotic Agents Antivirals (Systemic)...57 Blood Products/Modifiers/Volume Expanders Caloric Agents...68 Cardiovascular Agents Central Nervous System Agents Contraceptives...82 Dental And Oral Agents...90 Dermatological Agents...90 Devices...99 Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents

11 Vasodilating Agents Vitamins And Minerals

12 List of Drugs by Drug Type The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. Name of drug Analgesics Analgesics, Miscellaneous acetaminophen (bulk) powder 100 % acetaminophen oral drops 100 mg/ml acetaminophen oral elixir 160 mg/5 ml acetaminophen oral liquid 160 mg/5 ml, 500 mg/5 ml acetaminophen oral solution 160 mg/5 ml (5 ml) acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 325 mg acetaminophen oral tablet,disintegrating 80 mg acetaminophen rectal suppository 120 mg, 650 mg acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg, mg arthritis pain relief (acetam) oral tablet extended release 650 mg astramorph-pf injection solution 0.5 mg/ml, 1 mg/ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital-acetaminophen oral tablet mg, mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg QL (120 ML per 1 day) QL (8 EA per 1 day) QL (240 ML per 30 days) ; QL (4 EA per 28 days) QL (12 EA per 1 day) QL (12 EA per 1 day) QL (6 EA per 1 day) 3

13 butalbital-aspirin-caffeine oral tablet mg capsaicin topical cream % children's pain reliever oral tablet,chewable 80 mg children's pain-fever relief oral tablet,disintegrating 160 mg codeine sulfate oral tablet 15 mg, 30 mg, 60 mg endocet oral tablet mg endocet oral tablet mg, mg, mg extra strength muscle rub topical cream % fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 62.5 mcg/hour, 87.5 mcg/hour feverall rectal suppository 325 mg, 80 mg hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml hydromorphone injection syringe 0.5 mg/0.5 ml, 1 mg/ml, 2 mg/ml, 4 mg/ml QL (6 EA per 1 day) QL (240 EA per 30 days) QL (180 EA per 30 days) QL (8 EA per 1 day) QL (10 EA per 30 days) QL (30 EA per 30 days) QL (15 EA per 30 days) ; QL (10 EA per 30 days) QL (120 ML per 1 day) QL (8 EA per 1 day) QL (8 EA per 1 day) QL (240 ML per 30 days) QL (240 ML per 30 days) QL (240 ML per 30 days) 4

14 hydromorphone oral liquid 1 mg/ml hydromorphone oral tablet 2 mg hydromorphone oral tablet 4 mg hydromorphone oral tablet 8 mg LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet mg lorcet hd oral tablet mg lorcet plus oral tablet mg mapap (acetaminophen) oral capsule 500 mg mapap (acetaminophen) oral liquid 500 mg/15 ml marten-tab oral tablet mg methadone oral concentrate 10 mg/ml methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine (pf) injection solution 0.5 mg/ml morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) morphine oral solution 10 mg/5 ml QL (1200 ML per 30 days) QL (240 EA per 30 days) QL (150 EA per 30 days) QL (60 EA per 30 days) QL (8 EA per 1 day) QL (8 EA per 1 day) QL (8 EA per 1 day) QL (12 EA per 1 day) QL (90 ML per 30 days) QL (450 ML per 30 days) QL (900 ML per 30 days) QL (120 EA per 30 days) QL (240 EA per 30 days) QL (240 ML per 30 days) QL (120 ML per 30 days) QL (1350 ML per 30 days) 5

15 morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 15 mg morphine oral tablet extended release 30 mg morphine oral tablet extended release 60 mg muscle relief topical cream % non-aspirin infants oral drops,suspension 100 mg/ml oxycodone oral capsule 5 mg oxycodone oral concentrate 20 mg/ml oxycodone oral solution 5 mg/5 ml oxycodone oral tablet 10 mg oxycodone oral tablet 15 mg, 20 mg oxycodone oral tablet 5 mg oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg oxycodone oral tablet,oral only,ext.rel.12 hr 20 mg oxycodone oral tablet,oral only,ext.rel.12 hr 30 mg oxycodone oral tablet,oral only,ext.rel.12 hr 40 mg, 60 mg, 80 mg oxycodone-acetaminophen oral solution mg/5 ml QL (600 ML per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) QL (4 EA per 1 day) QL (90 EA per 30 days) QL (240 EA per 30 days) QL (120 ML per 30 days) QL (1800 ML per 30 days) QL (180 EA per 30 days) QL (120 EA per 30 days) QL (240 EA per 30 days) QL (120 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (40 ML per 1 day) 6

16 oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg, mg, mg oxycodone-aspirin oral tablet mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 20 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG pain relief (acetamin-asp-caf) oral tablet mg pain reliever extra strength oral tablet 500 mg sarna anti-itch topical lotion % tencon oral tablet mg tramadol oral tablet 50 mg Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet 325 mg aspirin oral tablet,chewable 81 mg aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg aspirin rectal suppository 300 mg bufferin oral tablet 325 mg celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg QL (180 EA per 30 days) QL (8 EA per 1 day) QL (240 EA per 30 days) QL (120 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (12 EA per 1 day) QL (8 EA per 1 day) 7

17 etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibu oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral capsule 200 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral tablet,chewable 100 mg indomethacin oral capsule 25 mg, 50 mg infant's ibuprofen oral drops,suspension 50 mg/1.25 ml ketorolac oral tablet 10 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 220 mg QL (20 EA per 30 days) 8

18 piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg ; QL (90 EA per 30 days) QL (360 EA per 30 days) QL (90 EA per 30 days) QL (360 EA per 30 days) QL (90 EA per 30 days) 9

19 bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE CK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION nicotine (polacrilex) buccal gum 2 mg, 4 mg nicotine (polacrilex) buccal lozenge 2 mg, 4 mg nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4-1 MG SUBOXONE SUBLINGUAL FILM 8-2 MG QL (2 EA per 1 day) QL (2 EA per 1 day) QL (53 EA per 28 days) QL (60 EA per 30 days) QL (360 EA per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) 10

20 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg alprazolam oral tablet 2 mg alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg alprazolam oral tablet extended release 24 hr 2 mg alprazolam oral tablet extended release 24 hr 3 mg buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 10 mg, 5 mg chlordiazepoxide hcl oral capsule 25 mg clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg diastat acudial rectal kit mg diastat acudial rectal kit mg QL (180 EA per 30 days) QL (150 EA per 30 days) QL (6 EA per 1 day) QL (5 EA per 1 day) QL (3 EA per 1 day) QL (180 EA per 30 days) QL (120 EA per 30 days) QL (180 EA per 30 days) QL (120 EA per 30 days) QL (300 EA per 30 days) QL (180 EA per 30 days) QL (120 EA per 30 days) QL (300 EA per 30 days) QL (180 EA per 30 days) QL (40 EA per 30 days) QL (20 EA per 30 days) 11

21 diastat rectal kit 2.5 mg diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg, 5 mg diazepam rectal kit mg, 2.5 mg diazepam rectal kit mg lorazepam intensol oral concentrate 2 mg/ml lorazepam oral concentrate 2 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG temazepam oral capsule 15 mg, 30 mg Antibacterials Aminoglycosides amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML QL (40 EA per 30 days) QL (240 ML per 30 days) QL (1200 ML per 30 days) QL (120 EA per 30 days) QL (180 EA per 30 days) QL (40 EA per 30 days) QL (20 EA per 30 days) QL (150 ML per 30 days) QL (150 ML per 30 days) QL (180 EA per 30 days) ; QL (480 ML per 30 days) ; QL (120 EA per 30 days) ; QL (60 EA per 30 days) QL (30 EA per 30 days) ; BvD; QL (224 ML per 30 days) 12

22 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg ; QL (224 EA per 30 days) ; BvD; QL (280 ML per 30 days) 13

23 daptomycin intravenous recon soln 500 mg linezolid in dextrose 5% intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral tablet 250 mg, 500 mg MONUROL ORAL CKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml SIVEXTRO INTRAVENOUS RECON SOLN 200 MG SIVEXTRO ORAL TABLET 200 MG SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg 14

24 XIFAXAN ORAL TABLET 200 MG, 550 MG Cephalosporins cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefepime in dextrose 5 % intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml cefepime injection recon soln 1 gram, 2 gram cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefoxitin intravenous recon soln 1 gram, 2 gram cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 1 gram, 2 gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg 15

25 ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml SUPRAX ORAL CAPSULE 400 MG TEFLARO INTRAVENOUS RECON SOLN 400 MG TEFLARO INTRAVENOUS RECON SOLN 600 MG Macrolides azithromycin intravenous recon soln 500 mg azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin oral capsule,delayed release(dr/ec) 250 mg 16

26 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram ; LA; QL (84 ML per 30 days) 17

27 BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) dicloxacillin oral capsule 250 mg, 500 mg nafcillin injection recon soln 1 gram, 2 gram nafcillin injection recon soln 10 gram nafcillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 20 million unit, 5 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg 18

28 moxifloxacin oral tablet 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfatrim oral suspension mg/5 ml Tetracyclines demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg minocycline oral capsule 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg 19

29 Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQO INTRAVENOUS RECON SOLN 60 MG ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE CK 90 MG (7)- 180 MG (23) anastrozole oral tablet 1 mg ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML, 100 MG/5 ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) 20

30 bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit, 30 unit BLINCYTO INTRAVENOUS KIT 35 MCG BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG busulfan intravenous solution 60 mg/10 ml BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15 ML CAPRELSA ORAL TABLET 100 MG, 300 MG carboplatin intravenous solution 10 mg/ml cisplatin intravenous solution 1 mg/ml cladribine intravenous solution 10 mg/10 ml clofarabine intravenous solution 20 mg/20 ml ; BvD ; LA ; BvD 21

31 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide oral capsule 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) cytarabine injection solution 20 mg/ml dacarbazine intravenous recon soln 100 mg, 200 mg dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML daunorubicin intravenous solution 5 mg/ml decitabine intravenous recon soln 50 mg docetaxel intravenous solution 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml, 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml doxorubicin, peg-liposomal intravenous suspension 2 mg/ml EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG epirubicin intravenous recon soln 50 mg ; LA BvD ; BvD ; BvD ; BvD ; BvD 22

32 epirubicin intravenous solution 200 mg/100 ml, 50 mg/25 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 200 MG/100 ML ERIVEDGE ORAL CAPSULE 150 MG ERLEADA ORAL TABLET 60 MG ERWINAZE INJECTION RECON SOLN 10,000 UNIT etoposide intravenous solution 20 mg/ml exemestane oral tablet 25 mg FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG fludarabine intravenous recon soln 50 mg fludarabine intravenous solution 50 mg/2 ml fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide oral capsule 125 mg FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 40 MG/2 ML (20 MG/ML) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML gemcitabine intravenous recon soln 1 gram, 2 gram, 200 mg ; LA ; BvD 23

33 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 100 mg/ml, 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 40 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG, 45 MG idarubicin intravenous solution 1 mg/ml IDHIFA ORAL TABLET 100 MG, 50 MG ifosfamide intravenous recon soln 1 gram, 3 gram ifosfamide intravenous solution 1 gram/20 ml, 3 gram/60 ml imatinib oral tablet 100 mg, 400 mg IMBRUVICA ORAL CAPSULE 140 MG, 70 MG IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) ; LA ; LA 24

34 IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML, 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 250 MG irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml ISTODAX INTRAVENOUS RECON SOLN 10 MG/2 ML IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML KISQALI FEMARA CO-CK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML ; BvD ; LA ; LA ; LA 25

35 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG, MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNRZA ORAL CAPSULE 50 MG LYNRZA ORAL TABLET 100 MG, 150 MG LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/31 ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG, 2 MG melphalan hcl intravenous recon soln 50 mg ; LA ; LA 26

36 mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg mitomycin intravenous recon soln 20 mg, 40 mg, 5 mg mitoxantrone intravenous concentrate 2 mg/ml MUSTARGEN INJECTION RECON SOLN 10 MG mutamycin intravenous recon soln 20 mg, 40 mg, 5 mg MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 200 MG nilutamide oral tablet 150 mg NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 240 MG/24 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 100 mg, 50 mg BvD BvD BvD ; LA 27

37 oxaliplatin intravenous solution 100 mg/20 ml, 50 mg/10 ml (5 mg/ml) paclitaxel intravenous concentrate 6 mg/ml PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML romidepsin intravenous recon soln 10 mg/2 ml RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG ; LA ; LA ; LA ; BvD ; LA 28

38 SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg topotecan intravenous recon soln 4 mg topotecan intravenous solution 4 mg/4 ml (1 mg/ml) TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML, 2 MG/ML 29

39 TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING CK ORAL TABLETS,DOSE CK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG vinblastine intravenous solution 1 mg/ml vincasar pfs intravenous solution 1 mg/ml, 2 mg/2 ml vincristine intravenous solution 1 mg/ml, 2 mg/2 ml vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG VYXEOS INTRAVENOUS RECON SOLN MG XALKORI ORAL CAPSULE 200 MG, 250 MG XATMEP ORAL SOLUTION 2.5 MG/ML XTANDI ORAL CAPSULE 40 MG ; LA ; BvD ; LA ; BvD ; LA 30

40 YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG YONSA ORAL TABLET 125 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML ; BvD ; LA ; LA ; QL (80 ML per 1 day) 31

41 BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 200 mg carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg epitol oral tablet 200 mg ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5 ml ; QL (16 EA per 1 day) ; QL (8 EA per 1 day) 32

42 felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FYCOM ORAL SUSPENSION 0.5 MG/ML FYCOM ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg QL (12 EA per 1 day) QL (9 EA per 1 day) QL (72 ML per 1 day) QL (6 EA per 1 day) QL (4 EA per 1 day) 33

43 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL SOLUTION 20 MG/ML oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml POTIGA ORAL TABLET 200 MG, 50 MG POTIGA ORAL TABLET 300 MG, 400 MG primidone oral tablet 250 mg, 50 mg SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG, 750 MG QL (3 EA per 1 day) QL (2 EA per 1 day) QL (30 ML per 1 day) QL (6 EA per 1 day) QL (3 EA per 1 day) ; LA 34